Risky Sexual Practice among Street Dwelling People in Southern Ethiopia: A mixed-Method Study

Background The number of street dwellers in major cities in Ethiopia is rapidly increasing. However, their sexual health needs are not that much studied. Hence, this study assessed risky sexual practice and associated factors among street dwelling people in southern Ethiopia. Methods A cross-sectional study employing a mixed method was conducted. For the quantitative part, a snowball sampling technique was made to conduct face-to-face interviews among 842 respondents. In-depth interviews among street dwellers and key informant interviews among stakeholders were conducted to collect qualitative data. A pre-tested and structured interviewer-administered questionnaire was used to collect data. The collected data were entered using Epidata and exported to SPSS for analysis, and qualitative data analyzed by thematic analysis approach. Results About one third, 266(31.6%), of the participants had risky sexual practices within the last year of the study period. Sexual violence such as gang rape and same-sex practice were reported qualitatively. Male respondents (AOR: 3.24, 95%CI: 2.09–5.02) had a more likelihood of risky sexual practice than females. Living in Dilla (AOR: 9.62, 95%CI: 4.49–20.58) and Wolaita Soddo towns (AOR: 14.35, 95%CI: 6.29–32.69) had also a more likelihood of risky sexual practice than living in Hawassa. Moreover, the daily average income of 21–50 Birr (AOR: 0.52, 95%CI: 0.29–0.92) had a less likelihood of risky sexual practice compared to those with a daily average income of 5–20 Birr. Conclusion Risky sexual practice among street dwelling people is found high. The Federal Ministry of Health and other stakeholders should work to cut risky sexual practices among street dwelling people.


INTRODUCTION
A person's sexuality is shaped by his/her values, attitudes, behaviors, and all the ways in which he/she has been socialized (1). Sexuality and disclosure of information related to sexual matters is considered to be a social taboo in certain society (2). Many young people engage in sexual activity before marriage and do so at an early age often without any protection against pregnancy and sexually transmitted disease (STDs) (3). This could increase the sexual and reproductive health risk of street dwelling people in the general and female street dwellers in particular (2). Street dwellers are people literally living on the streets abandoned by their families, or they may have no family members left alive and move from friend to friend, or live in shelters (4,5). In general, street dwellers are at greater risk of sexual and reproductive health problems due to risky sexual behaviors (2,6).
Sexual violence including rape is very common among street dwelling people (7,6). Moreover, most females living on the street are sexually active and vulnerable to sexual abuse and exploitation compared to street males, while commercial sex work and rape are prevalent among both sexes (2). Similarly, most of the girls living on the street feel sexual abuse as unavoidable violence for girls particularly for newcomers and young dwellers. Hence, they admitted being involved in sexual activity of commercial nature as a means of survival (8,9).
Reproductive health service use by young people is limited in Ethiopia due to the lack of adequate facility, health worker attitudes, cultural barriers, and financial vulnerability of the adolescents (10)(11)(12)(13)(14). Further, youth-friendly service utilization by street dwelling people is low because they have not been targeted and could not easily access reproductive health services (15).
The number of street people in major cities of Ethiopia is dramatically increasing from time to time because of financial problems and due to their prior life situation (16,2). In addition, circumstances in which they live and work increase their vulnerability to sexual exploitation and abuse and put them at a higher risk of unwanted pregnancies, STD, and mental health problems (7,(17)(18)(19). The problem was further compounded by the lack of access to sexual and reproductive health information and services (19,20). Risky sexual practices from the reproductive health perspective are of concern for which scientific investigation is lacking among both sexes (21,12). Even though studies on the sexual behavior of street youths in Ethiopia indicated that they are sexually active at an early age and practice risky sexual behavior (4,20,22) one important limitation of these studies was that they were only conducted among children and also addressed only female street dwellers (20,15,18,16,4,21). Therefore, this study aimed to assess risky sexual practice and its associated factors among street dwelling reproductive age groups of people in southern Ethiopia.

Study design and setting:
A mixed-method study design was conducted among street dwelling people in Southern Nation, Nationality, and People Regional State (SNNPRS) from February 12 to March 10, 2019. SNNPRS is one of the nine Federal Democratic Republic of Ethiopian regional states and the third-largest region in the country comprising an estimated 18, 416,289 inhabitants. Hawassa is the capital city of the state with an estimated number of 328, 875 inhabitants and a rapidly growing number of street children and women (20). All street dwelling reproductive age groups in the SNNPRS were considered as the study population (23). Sample size and sampling procedure: The sample size was determined by using the single population proportion formula with the following assumptions: 95% confidence level, 5% margin of error, and taking 50% proportions (p) since there are no earlier studies conducted on similar study subjects addressed both sexes. A simple random sampling technique was employed to select seven cities (Arba Minch, Dilla, Durame, Hawassa, Mizan Aman, Soddo, and Yirgalem) among fifteen cities in the region. A preliminary survey was conducted to determine an estimated number of street reproductive age group and the venues that street dwellers often used for the purpose of survival work. Finally, 845 samples were allocated proportionally to each selected city. Then, snowball sampling technique was used to recruit the representative sample size. A data saturation point was used to determine the sample size for the qualitative study. Accordingly, a total of twenty-one in-depth interviews and ten key informant interviews were carried out (23). Data collection tools and procedures: The first set of data collection tools constitutes a pre-tested and structured intervieweradministered questionnaire to collect quantitative data. Different relevant literatures were reviewed to develop a tool that addresses the objectives of the study (3,(8)(9)(10)(11)(12)(13)(14)(15)(18)(19)(20)21).
The pre-test was conducted among 50 street reproductive age groups in Hosanna Town. The result of the pre-test was used to modify the instrument. The questionnaire was designed to assess socio-demographic characteristics, sexual activity, and education. Four Bachelor of Science in midwifery who had experience in quantitative and qualitative field data collection were used as data collectors, and two Master's of Science degree holders were employed as a supervisors (23).The second set of data collection tool constitutes unstructured questions which were designed to serve as a guide for in-depth and key informants' interviews to collect qualitative data.
A separate guiding checklist was used for male street respondents with a history of risky sexual practice and female street respondents with a history of sexual assault. The guiding checklist for an in-depth interview constitutes sexual experience (when and how sexual act occurred). To dig out all basic information, more neutral questions were asked first, and then the most important and more sensitive questions were asked at last for both qualitative and quantitative data collections from the street dwellers.
Similarly, a guiding checklist for key informants' interview constitutes service year, service they had been providing for street people, reproductive health problems that street people had faced and responsibility of their sectors to solve the reproductive health problems of street people and how they had approached street people in their cities. Based on their permission, the voices of the respondents were recorded by the sound recorder, and notes were taken during the interview for the qualitative part of the study.
Data quality control: The quality of data was assured by properly designing and pre-testing the tool, and giving training for the data collectors and supervisors before the actual data collection.
The data collectors and supervisors were trained before the actual work about the aim of the study, procedures, how to approach the study participants, and data collection techniques. Every day after data collection, data were reviewed and checked for completeness, accuracy, and clarity by the supervisors, and the necessary feedback was offered to data collectors the next morning. Data cleanup and cross-checking were done before analysis (23).

Data management and analysis:
The quantitative data were checked manually for completeness, coded, and entered into Epidata version 3.1. After the entry, the data was exported to SPSS version 23.0 for further analysis. The descriptive results were presented in the form of tables, figures, and texts using frequencies and summary statistics such as mean, standard deviation, and percentage. Binary logistic regression was used to determine the association of independent variables with the risky sexual practice and the association of all independent variables was also checked with the response variable at the same time to adjust the influence of the likelihood of various independent variables (confounding effects) on the outcome variable. All variables having a pvalue less than 0.25 were included in multivariate analysis. Odds ratio with 95% confidence interval and p-value was used to identify the significant variables. And, variables with P-value less than or equal to 0.05 were considered significant. Regarding the qualitative part, responses from both in-depth and key informant interviews were transcribed in their respective local languages and then translated into English. Keywords and sentences were extracted from the transcribed interview for textual analysis (23).
Operational definitions: Individuals who are dependent on the street for their life and sleep on the street were considered as street "off" while people who depend on the street for their subsistence, but usually return home at night were considered as street "on" (5,23).
Risky sexual practice: Street reproductive age groups who had sex with a non-regular sexual partner or exchanged sex for money, or have more than one sexual partner, or have had rape in the last one year of the study, or not use condoms or use inconsistently in the last three months. Those respondents who had one or more of these were considered as having risky sexual practice.
Ethics: Ethical approval was obtained from Hawassa University, College of Medicine and Health Sciences Ethical Review Board with a permit number of IRB/015/10. A letter of permission was obtained from the SNNPR Health Bureau to respective zonal health departments. Each respondent was informed about the objective of the study that it contributes necessary information for policymakers and other concerned bodies. They were also informed that all the data obtained from them would be kept confidential by using codes instead of any personal identifiers and is meant only for the purpose of the study. Finally, written and verbal consent was obtained from each study participant prior to the data collection (23).

Socio-demographic characteristics of the respondents:
A total of 842 street dwellers were included in the study with a response rate of 99. 6%. More than half, 503(59.7%), of them were males. The mean age of the respondents was 22.95 years (SD: ±6.79) (Table1). Attitude towards street dwellers: Regarding the attitude of the communities towards street dwelling people, lack of awareness by the community about street dwelling people and assuming all street dwellers as a burglar by the community members were mentioned during an interview. Moreover, the attitude of the government sectors particularly police officers found to be an additional challenge for street-dwelling people. The communities and family have fear on the street dwellers because they think that they might negatively influence the behavior of their child and even some families challenge one to receive their child back to home from street life. The key informant interview from Integrated Service on Health and Development Organization coordinator also indicated that: "…if the street dwellers report to police that he/she is raped, usually they claimed them as they provoke for the sexual act, this paramount if she/he is a commercial sex worker."

Reasons for joining street life and source of
In supporting the above idea, a senior staff from Justice and Security Office said: "Some of our communities think that all street dwelling people are bad-mannered and aimless. Even if they want to be engaged in daily labor, most of our community could not believe street dwelling people. This is very dangerous."

Sexual activity and risky sexual practice:
About two-thirds, 571(67.8%), of the respondents ever had sexual intercourse. The minimum age at which they had their first sexual intercourse was 8 years with the mean age of 16. 71 years. About 56(6.8%) of the respondents thought they ever had more than ten sexual partners in their lifetime. Moreover, 266(31.6%) of the street dwellers had at least one risky sexual practice in the last year of the study  (Table 3).